Nokea
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement?
- A. Give an around-the-clock schedule for administration of analgesics.
- B. Administer analgesic medication as needed when the pain is severe.
- C. Provide medication to keep the client sedated and unaware of stimuli.
- D. Offer a medication-free period to allow the client to engage in daily activities.
Correct Answer: A
Rationale: The correct action for the LPN/LVN to implement is to give an around-the-clock schedule for administration of analgesics. This approach helps maintain consistent pain management by providing the medication regularly, preventing the pain from becoming severe. Choice B is incorrect because waiting for severe pain before administering the analgesic may lead to uncontrolled pain levels. Choice C is inappropriate as the goal of pain management in hospice care is to provide comfort without unnecessary sedation. Choice D is also incorrect as offering a medication-free period may result in inadequate pain control for the client.
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While auscultating a client's abdomen, a nurse hears a blowing sound over the aorta. The nurse should identify this sound as which of the following?
- A. Gallop
- B. Bruit
- C. Thrill
- D. Murmur
Correct Answer: B
Rationale: The correct answer is B: Bruit. A bruit is a blowing sound indicating turbulent blood flow, often heard over the aorta. Choices A, C, and D are incorrect. A gallop is a cardiac sound resembling the sound of a galloping horse. A thrill is a vibration felt on palpation, and a murmur is a swooshing or whooshing sound heard during auscultation of the heart or blood vessels. In this scenario, the blowing sound over the aorta specifically indicates a bruit, which signifies turbulent blood flow and should be further assessed by the healthcare provider.
The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe?
- A. Tops of the ears
- B. Bridge of the nose
- C. Around the nostrils
- D. Over the cheeks
Correct Answer: A
Rationale: When a client is using a nasal cannula for oxygen therapy, the areas prone to skin damage are the tops of the ears and around the nostrils. The pressure exerted by the cannula on these areas can lead to skin breakdown, so it is important for the nurse to observe these sites for any signs of damage. The correct answer is 'Tops of the ears.' Choices 'Bridge of the nose' and 'Over the cheeks' are not typically areas where skin damage related to the cannula would occur, making them incorrect choices.
During a Weber test, what is an appropriate action for the nurse to take?
- A. Deliver a series of high-pitched sounds at random intervals.
- B. Place an activated tuning fork in the middle of the client's forehead.
- C. Hold an activated tuning fork against the client's mastoid process.
- D. Whisper a series of words softly into one ear.
Correct Answer: B
Rationale: During a Weber test, the nurse should place an activated tuning fork in the middle of the client's forehead. This test is used to assess for lateralization of sound in a client with possible hearing issues. Choice A is incorrect because the Weber test does not involve delivering high-pitched sounds at random intervals. Choice C is incorrect as it describes the Rinne test, not the Weber test. Choice D is incorrect as whispering words into one ear is not part of the Weber test procedure.
A 25-year-old primigravida at 16 weeks gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. Which nursing diagnosis should have the highest priority?
- A. Fluid volume deficit
- B. Altered nutrition: less than body requirements
- C. Anxiety related to new situational crisis
- D. Activity intolerance related to fatigue
Correct Answer: A
Rationale: In a case of hyperemesis gravidarum, the priority nursing diagnosis should be addressing the Fluid volume deficit. This condition can lead to serious complications such as electrolyte imbalances and dehydration, which can endanger both the mother and the fetus if not managed promptly. Altered nutrition: less than body requirements is important but addressing the fluid volume deficit takes precedence as it poses an immediate threat. Anxiety related to new situational crisis and Activity intolerance related to fatigue are valid concerns, but they are secondary to the critical issue of fluid volume deficit in this scenario.
A client has pharyngeal diphtheria. What transmission precautions are necessary?
- A. Droplet
- B. Contact
- C. Airborne
- D. Standard
Correct Answer: A
Rationale: Pharyngeal diphtheria is primarily spread through droplet transmission, which occurs when an infected person coughs, sneezes, or talks, releasing respiratory droplets containing the bacteria. Therefore, the correct precaution for caring for a client with pharyngeal diphtheria is droplet precautions. Droplet precautions help prevent the transmission of respiratory pathogens over short distances via respiratory droplets. Contact precautions are used for diseases spread through direct or indirect contact with the patient or their environment. Airborne precautions are used for diseases that spread through small droplets suspended in the air. Standard precautions are basic infection prevention practices applying to all patient care.